1.

A postpartum nurse is preparing to care for a woman who has just delivered a
healthy newborn infant. In the immediate postpartum period the nurse plans to take
the womans vital signs:
1. Every 30 minutes during the first hour and then every hour for the next two hours.
2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
3. Every hour for the first 2 hours and then every 4 hours
4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
2. A postpartum nurse is taking the vital signs of a woman who delivered a healthy
newborn infant 4 hours ago. The nurse notes that the mothers temperature is
100.2*F. Which of the following actions would be most appropriate?
1. Retake the temperature in 15 minutes
2. Notify the physician
3. Document the findings
4. Increase hydration by encouraging oral fluids
3. The nurse is assessing a client who is 6 hours PP after delivering a full-term
healthy infant. The client complains to the nurse of feelings of faintness and
dizziness. Which of the following nursing actions would be most appropriate?
1. Obtain hemoglobin and hematocrit levels
2. Instruct the mother to request help when getting out of bed
3. Elevate the mothers legs
4. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the
feelings of lightheadedness and dizziness have subsided.
4. A nurse is preparing to perform a fundal assessment on a postpartum client. The
initial nursing action in performing this assessment is which of the following?
1. Ask the client to turn on her side
2. Ask the client to lie flat on her back with the knees and legs flat and straight.
3. Ask the mother to urinate and empty her bladder
4. Massage the fundus gently before determining the level of the fundus.
5. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the
lochia is red and has a foul-smelling odor. The nurse determines that this
assessment finding is:
1. Normal
2. Indicates the presence of infection
3. Indicates the need for increasing oral fluids
4. Indicates the need for increasing ambulation
6. When performing a PP assessment on a client, the nurse notes the presence of
clots in the lochia. The nurse examines the clots and notes that they are larger than 1
cm. Which of the following nursing actions is most appropriate?
1. Document the findings
2. Notify the physician
3. Reassess the client in 2 hours
4. Encourage increased intake of fluids.
7. A nurse in a PP unit is instructing a mother regarding lochia and the amount of
expected lochia drainage. The nurse instructs the mother that the normal amount of
lochia may vary but should never exceed the need for:
1. One peripad per day
2. Two peripads per day
3. Three peripads per day
4. Eight peripads per day
8. A PP nurse is providing instructions to a woman after delivery of a healthy
newborn infant. The nurse instructs the mother that she should expect normal bowel
elimination to return:
1. One the day of the delivery
2. 3 days PP
3. 7 days PP
4. within 2 weeks PP
9. Select all of the physiological maternal changes that occur during the PP period.
1. Cervical involution ceases immediately
2. Vaginal distention decreases slowly
3. Fundus begins to descend into the pelvis after 24 hours
4. Cardiac output decreases with resultant tachycardia in the first 24 hours
5. Digestive processes slow immediately.
10. A nurse is caring for a PP woman who has received epidural anesthesia and is
monitoring the woman for the presence of a vulva hematoma. Which of the following
assessment findings would best indicate the presence of a hematoma?
1. Complaints of a tearing sensation
2. Complaints of intense pain
3. Changes in vital signs
4. Signs of heavy bruising
11. A nurse is developing a plan of care for a PP woman with a small vulvar
hematoma. The nurse includes which specific intervention in the plan during the first
12 hours following the delivery of this client?
1. Assess vital signs every 4 hours
2. Inform health care provider of assessment findings
3. Measure fundal height every 4 hours
4. Prepare an ice pack for application to the area.
12. A new mother received epidural anesthesia during labor and had a forceps
delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has
dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120
beats per minute. The client is anxious and restless. On further assessment, a vulvar
hematoma is verified. After notifying the health care provider, the nurse immediately
plans to:
1. Monitor fundal height
2. Apply perineal pressure
3. Prepare the client for surgery.
4. Reassure the client
13. A nurse is monitoring a new mother in the PP period for signs of hemorrhage.
Which of the following signs, if noted in the mother, would be an early sign of
excessive blood loss?
1. A temperature of 100.4*F
2. An increase in the pulse from 88 to 102 BPM
3. An increase in the respiratory rate from 18 to 22 breaths per minute
4. A blood pressure change from 130/88 to 124/80 mm Hg
14. A nurse is preparing to assess the uterine fundus of a client in the immediate
postpartum period. When the nurse locates the fundus, she notes that the uterus
feels soft and boggy. Which of the following nursing interventions would be most
appropriate initially?
1. Massage the fundus until it is firm
2. Elevate the mothers legs
3. Push on the uterus to assist in expressing clots
4. Encourage the mother to void
15. A PP nurse is assessing a mother who delivered a healthy newborn infant by C-
section. The nurse is assessing for signs and symptoms of superficial venous
thrombosis. Which of the following signs or symptoms would the nurse note if
superficial venous thrombosis were present?
1. Paleness of the calf area
2. Enlarged, hardened veins
3. Coolness of the calf area
4. Palpable dorsalis pedis pulses
16. A nurse is providing instructions to a mother who has been diagnosed with
mastitis. Which of the following statements if made by the mother indicates a need
for further teaching?
1. I need to take antibiotics, and I should begin to feel better in 24-48 hours.
2. I can use analgesics to assist in alleviating some of the discomfort.
3. I need to wear a supportive bra to relieve the discomfort.
4. I need to stop breastfeeding until this condition resolves.
17. A PP client is being treated for DVT. The nurse understands that the clients
response to treatment will be evaluated by regularly assessing the client for:
1. Dysuria, ecchymosis, and vertigo
2. Epistaxis, hematuria, and dysuria
3. Hematuria, ecchymosis, and epistaxis
4. Hematuria, ecchymosis, and vertigo
18. A nurse performs an assessment on a client who is 4 hours PP. The nurse notes
that the client has cool, clammy skin and is restless and excessively thirsty. The
nurse prepares immediately to:
1. Assess for hypovolemia and notify the health care provider
2. Begin hourly pad counts and reassure the client
3. Begin fundal massage and start oxygen by mask
4. Elevate the head of the bed and assess vital signs
19. A nurse is assessing a client in the 4th stage if labor and notes that the fundus is
firm but that bleeding is excessive. The initial nursing action would be which of the
following?
1. Massage the fundus
2. Place the mother in the Trendelenburgs position
3. Notify the physician
4. Record the findings
20. A nurse is caring for a PP client with a diagnosis of DVT who is receiving a
continuous intravenous infusion of heparin sodium. Which of the following
laboratory results will the nurse specifically review to determine if an effective and
appropriate dose of the heparin is being delivered?
1. Prothrombin time
2. International normalized ratio
3. Activated partial thromboplastin time
4. Platelet count
21. A nurse is preparing a list of self-care instructions for a PP client who was
diagnosed with mastitis. Select all instructions that would be included on the list.
1. Take the prescribed antibiotics until the soreness subsides.
2. Wear supportive bra
3. Avoid decompression of the breasts by breastfeeding or breast pump
4. Rest during the acute phase
5. Continue to breastfeed if the breasts are not too sore.
22. Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before
administration of these medications, the priority nursing assessment is to check the:
1. Amount of lochia
2. Blood pressure
3. Deep tendon reflexes
4. Uterine tone
23. Methergine or pitocin are prescribed for a client with PP hemorrhage. Before
administering the medication(s), the nurse contacts the health provider who
prescribed the medication(s) in which of the following conditions is documented in
the clients medical history?
1. Peripheral vascular disease
2. Hypothyroidism
3. Hypotension
4. Type 1 diabetes
24. Which of the following factors might result in a decreased supply of breastmilk in
a PP mother?
1. Supplemental feedings with formula
2. Maternal diet high in vitamin C
3. An alcoholic drink
4. Frequent feedings
25. Which of the following interventions would be helpful to a breastfeeding mother
who is experiencing engorged breasts?
1. Applying ice
2. Applying a breast binder
3. Teaching how to express her breasts in a warm shower
4. Administering bromocriptine (Parlodel)
26. On completing a fundal assessment, the nurse notes the fundus is situated on the
clients left abdomen. Which of the following actions is appropriate?
1. Ask the client to empty her bladder
2. Straight catheterize the client immediately
3. Call the clients health provider for direction
4. Straight catheterize the client for half of her uterine volume
27. The nurse is about the give a Type 2 diabetic her insulin before breakfast on her
first day postpartum. Which of the following answers best describes insulin
requirements immediately postpartum?
1. Lower than during her pregnancy
2. Higher than during her pregnancy
3. Lower than before she became pregnant
4. Higher than before she became pregnant
28. Which of the following findings would be expected when assessing the
postpartum client?
1. Fundus 1 cm above the umbilicus 1 hour postpartum
2. Fundus 1 cm above the umbilicus on postpartum day 3
3. Fundus palpable in the abdomen at 2 weeks postpartum
4. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2
29. A client is complaining of painful contractions, or afterpains, on postpartum day
2. Which of the following conditions could increase the severity of afterpains?
1. Bottle-feeding
2. Diabetes
3. Multiple gestation
4. Primiparity
30. On which of the postpartum days can the client expect lochia serosa?
1. Days 3 and 4 PP
2. Days 3 to 10 PP
3. Days 10-14 PP
4. Days 14 to 42 PP
31. Which of the following behaviors characterizes the PP mother in the taking
inphase?
1. Passive and dependant
2. Striving for independence and autonomy
3. Curious and interested in care of the baby
4. Exhibiting maximum readiness for new learning
32. Which of the following complications may be indicated by continuous seepage of
blood from the vagina of a PP client, when palpation of the uterus reveals a firm
uterus 1 cm below the umbilicus?
1. Retained placental fragments
2. Urinary tract infection
3. Cervical laceration
4. Uterine atony
33. What type of milk is present in the breasts 7 to 10 days PP?
1. Colostrum
2. Hind milk
3. Mature milk
4. Transitional milk
34. Which of the following complications is most likely responsible for a delayed
postpartum hemorrhage?
1. Cervical laceration
2. Clotting deficiency
3. Perineal laceration
4. Uterine subinvolution
35. Before giving a PP client the rubella vaccine, which of the following facts should
the nurse include in client teaching?
1. The vaccine is safe in clients with egg allergies
2. Breast-feeding isnt compatible with the vaccine
3. Transient arthralgia and rash are common adverse effects
4. The client should avoid getting pregnant for 3 months after the vaccine because the
vaccine has teratogenic effects
36. Which of the following changes best described the insulin needs of a client with
type 1 diabetes who has just delivered an infant vaginally without complications?
1. Increase
2. Decrease
3. Remain the same as before pregnancy
4. Remain the same as during pregnancy
37. Which of the following responses is most appropriate for a mother with diabetes
who wants to breastfeed her infant but is concerned about the effects of
breastfeeding on her health?
1. Mothers with diabetes who breastfeed have a hard time controlling their insulin needs
2. Mothers with diabetes shouldnt breastfeed because of potential complications
3. Mothers with diabetes shouldnt breastfeed; insulin requirements are doubled.
4. Mothers with diabetes may breastfeed; insulin requirements may decrease from
breastfeeding.
38. On the first PP night, a client requests that her baby be sent back to the nursery
so she can get some sleep. The client is most likely in which of the following
phases?
1. Depression phase
2. Letting-go phase
3. Taking-hold phase
4. Taking-in phase
39. Which of the following physiological responses is considered normal in the early
postpartum period?
1. Urinary urgency and dysuria
2. Rapid diuresis
3. Decrease in blood pressure
4. Increase motility of the GI system
40. During the 3rd PP day, which of the following observations about the client would
the nurse be most likely to make?
1. The client appears interested in learning about neonatal care
2. The client talks a lot about her birth experience
3. The client sleeps whenever the neonate isnt present
4. The client requests help in choosing a name for the neonate.
41. Which of the following circumstances is most likely to cause uterine atony and
lead to PP hemorrhage?
1. Hypertension
2. Cervical and vaginal tears
3. Urine retention
4. Endometritis
42. Which type of lochia should the nurse expect to find in a client 2 days PP?
1. Foul-smelling
2. Lochia serosa
3. Lochia alba
4. Lochia rubra
43. After expulsion of the placenta in a client who has six living children, an infusion
of lactated ringers solution with 10 units of pitocin is ordered. The nurse
understands that this is indicated for this client because:
1. She had a precipitate birth
2. This was an extramural birth
3. Retained placental fragments must be expelled
4. Multigravidas are at increased risk for uterine atony.
44. As part of the postpartum assessment, the nurse examines the breasts of a
primiparous breastfeeding woman who is one day postpartum. An expected finding
would be:
1. Soft, non-tender; colostrum is present
2. Leakage of milk at let down
3. Swollen, warm, and tender upon palpation
4. A few blisters and a bruise on each areola
45. Following the birth of her baby, a woman expresses concern about the weight she
gained during pregnancy and how quickly she can lose it now that the baby is born.
The nurse, in describing the expected pattern of weight loss, should begin by telling
this woman that:
1. Return to pre pregnant weight is usually achieved by the end of the postpartum period
2. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight
loss
3. The expected weight loss immediately after birth averages about 11 to 13 pounds
4. Lactation will inhibit weight loss since caloric intake must increase to support milk
production
46. Which of the following findings would be a source of concern if noted during the
assessment of a woman who is 12 hours postpartum?
1. Postural hypotension
2. Temperature of 100.4F
3. Bradycardia pulse rate of 55 BPM
4. Pain in left calf with dorsiflexion of left foot
47. The nurse examines a woman one hour after birth. The womans fundus is
boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two
plum-sized clots. The nurses initial action would be to:
1. Place her on a bedpan to empty her bladder
2. Massage her fundus
3. Call the physician
4. Administer Methergine 0.2 mg IM which has been ordered prn
48. When performing a postpartum check, the nurse should:
1. Assist the woman into a lateral position with upper leg flexed forward to facilitate the
examination of her perineum
2. Assist the woman into a supine position with her arms above her head and her legs
extended for the examination of her abdomen
3. Instruct the woman to avoid urinating just before the examination since a full bladder will
facilitate fundal palpation
4. Wash hands and put on sterile gloves before beginning the check
49. Perineal care is an important infection control measure. When evaluating a
postpartum womans perineal care technique, the nurse would recognize the need for
further instruction if the woman:
1. Uses soap and warm water to wash the vulva and perineum
2. Washes from symphysis pubis back to episiotomy
3. Changes her perineal pad every 2 3 hours
4. Uses the peribottle to rinse upward into her vagina
50. Which measure would be least effective in preventing postpartum hemorrhage?
1. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered
2. Encourage the woman to void every 2 hours
3. Massage the fundus every hour for the first 24 hours following birth
4. Teach the woman the importance of rest and nutrition to enhance healing
51. When making a visit to the home of a postpartum woman one week after birth, the
nurse should recognize that the woman would characteristically:
1. Express a strong need to review events and her behavior during the process of labor and
birth
2. Exhibit a reduced attention span, limiting readiness to learn
3. Vacillate between the desire to have her own nurturing needs met and the need to take
charge of her own care and that of her newborn
4. Have reestablished her role as a spouse/partner
52. Four hours after a difficult labor and birth, a primiparous woman refuses to feed
her baby, stating that she is too tired and just wants to sleep. The nurse should:
1. Tell the woman she can rest after she feeds her baby
2. Recognize this as a behavior of the taking-hold stage
3. Record the behavior as ineffective maternal-newborn attachment
4. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this
time
53. Parents can facilitate the adjustment of their other children to a new baby by:
1. Having the children choose or make a gift to give to the new baby upon its arrival home
2. Emphasizing activities that keep the new baby and other children together
3. Having the mother carry the new baby into the home so she can show the other children
the new baby
4. Reducing stress on other children by limiting their involvement in the care of the new
baby
54. A primiparous woman is in the taking-in stage of psychosocial recovery and
adjustment following birth. The nurse, recognizing the needs of women during this
stage, should:
1. Foster an active role in the babys care
2. Provide time for the mother to reflect on the events of and her behavior during childbirth
3. Recognize the womans limited attention span by giving her written materials to read
when she gets home rather than doing a teaching session now
4. Promote maternal independence by encouraging her to meet her own hygiene and
comfort needs
55. All of the following are important in the immediate care of the premature neonate.
Which nursing activity should have the greatest priority?
1. Instillation of antibiotic in the eyes
2. Identification by bracelet and foot prints
3. Placement in a warm environment
4. Neurological assessment to determine gestational age
Answers and Rationale
Gauge your performance by counter checking your answers to the answers below. Learn
more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
1. Answer: 2. Every 15 minutes during the first hour and then every 30 minutes for
the next two hours.
2. Answer: 4. Increase hydration by encouraging oral fluids. The mothers temperature
may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first
24 hours after birth are often related to the dehydrating effects of labor. The most
appropriate action is to increase hydration by encouraging oral fluids, which should bring
the temperature to a normal reading. Although the nurse would document the findings, the
most appropriate action would be to increase the hydration.
3. Answer: 2. Instruct the mother to request help when getting out of bed. Orthostatic
hypotension may be evident during the first 8 hours after birth. Feelings of faintness or
dizziness are signs that should caution the nurse to be aware of the clients safety. The
nurse should advise the mother to get help the first few times the mother gets out of bed.
Obtaining an H/H requires a physicians order.
4. Answer: 3. Ask the mother to urinate and empty her bladder. Before starting the
fundal assessment, the nurse should ask the mother to empty her bladder so that an
accurate assessment can be done. When the nurse is performing fundal assessment, the
nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is
not appropriate unless the fundus is boggy and soft, and then it should be massaged gently
until firm.
5. Answer: 2. Indicates the presence of infection. Lochia, the discharge present after
birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a
fleshy odor. Foul smelling or purulent lochia usually indicates infection, and these findings
are not normal. Encouraging the woman to drink fluids or increase ambulation is not an
accurate nursing intervention.
6. Answer: 2. Notify the physician. Normally, one may find a few small clots in the first 1
to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are
considered abnormal. The cause of these clots, such as uterine atony or retained placental
fragments, needs to be determined and treated to prevent further blood loss. Although the
findings would be documented, the most appropriate action is to notify the physician.
7. Answer: 4. Eight peripads per day. The normal amount of lochia may vary with the
individual but should never exceed 4 to 8 peripads per day. The average number of
peripads is 6 per day.
8. Answer: 2. 3 days PP. After birth, the nurse should auscultate the womans abdomen in
all four quadrants to determine the return of bowel sounds. Normal bowel elimination
usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain
control agents also contribute to the longer period of altered bowel function.
9. Answer: 1 and 3. In the PP period, cervical healing occurs rapidly and cervical
involution occurs.After 1 week the muscle begins to regenerate and the cervix feels firm
and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal
distention decreases, it takes the entire PP period for complete involution to occur and
muscle tone is never restored to the pregravid state. The fundus begins to descent into the
pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs
during delivery of the baby, a transient increase in cardiac output occurs. The increase in
cardiac output, which persists about 48 hours after childbirth, is probably caused by an
increase in stroke volume because Bradycardia is often noted during the PP period. Soon
after childbirth, digestion begins to begin to be active and the new mother is usually hungry
because of the energy expended during labor.
10. Answer: 3. Changes in vital signs. Because the woman has had epidural anesthesia
and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in
vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy
bruising may be visualized, but vital sign changes indicate hematoma caused by blood
collection in the perineal tissues.
11. Answer: 4. Prepare an ice pack for application to the area. Application of ice will
reduce swelling caused by hematoma formation in the vulvar area. The other options are
not interventions that are specific to the plan of care for a client with a small vulvar
hematoma.
12. Answer: 3. Prepare the client for surgery. The use of an epidural, prolonged second
stage labor and forceps delivery are predisposing factors for hematoma formation, and a
collection of up to 500 ml of blood can occur in the vaginal area. Although the other options
may be implemented, the immediate action would be to prepare the client for surgery to
stop the bleeding.
13. Answer: 2. An increase in the pulse from 88 to 102 BPM. During the 4th stage of
labor, the maternal blood pressure, pulse, and respiration should be checked every 15
minutes during the first hour. A rising pulse is an early sign of excessive blood loss because
the heart pumps faster to compensate for reduced blood volume. The blood pressure will
fall as the blood volume diminishes, but a decreased blood pressure would not be the
earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is
increased slightly.
14. Answer: 1. Massage the fundus until it is firm. If the uterus is not contracted firmly,
the first intervention is to massage the fundus until it is firm and to express clots that may
have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus
and cause massive hemorrhage. Elevating the clients legs and encouraging the client to
void will not assist in managing uterine atony. If the uterus does not remain contracted as a
result of the uterine massage, the problem may be distended bladder and the nurse should
assist the mother to urinate, but this would not be the initial action.
15. Answer: 2. Enlarged, hardened veins. Thrombosis of the superficial veins is usually
accompanied by signs and symptoms of inflammation. These include swelling of the
involved extremity and redness, tenderness, and warmth.
16. Answer: 4. I need to stop breastfeeding until this condition resolves. In most
cases, the mother can continue to breastfeed with both breasts. If the affected breast is too
sore, the mother can pump the breast gently. Regular emptying of the breast is important to
prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48
hours. Additional supportive measures include ice packs, breast supports, and analgesics.
17. Answer: 3. Hematuria, ecchymosis, and epistaxis. The treatment for DVT is
anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of
anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are
not associated specifically with bleeding.
18. Answer: 1. Assess for hypovolemia and notify the health care provider. Symptoms
of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom,
restlessness, and thirst. When these symptoms are present, the nurse should further
assess for hypovolemia and notify the health care provider.
19. Answer: 3. Notify the physician. If the bleeding is excessive, the cause may be
laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in
controlling the bleeding. Trendelenburgs position is to be avoided because it may interfere
with cardiac function.
20. 3. Activated partial thromboplastin time. Anticoagulation therapy may be used to
prevent the extension of thrombus by delaying the clotting time of the blood. Activated
partial thromboplastin time should be monitored, and a heparin dose should be adjusted to
maintain a therapeutic level of 1.5 to 2.5 times the control. The prothrombin time and the
INR are used to monitor coagulation time when warfarin (Coumadin) is used.
21. Answer: 2, 4, and 5. Mastitis are an infection of the lactating breast. Client instructions
include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and
taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the
complete prescribed course is finished. They are not stopped when the soreness subsides.
Additional supportive measures include the use of moist heat or ice packs and wearing a
supportive bra. Continued decompression of the breast by breastfeeding or pumping is
important to empty the breast and prevent formation of an abscess.
22. Answer: 2. Blood pressure. Methergine and pitocin are agents that are used to
prevent or control postpartum hemorrhage by contracting the uterus. They cause
continuous uterine contractions and may elevate blood pressure. A priority nursing
intervention is to check blood pressure. The physician should be notified if hypertension is
present.
23. Answer: 1. Peripheral vascular disease. These medications are avoided in clients
with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or
preeclampsia. These conditions are worsened by the vasoconstriction effects of these
medications.
24. Answer: 1. Supplemental feedings with formula. Routine formula supplementation
may interfere with establishing an adequate milk volume because decreased stimulation to
the mothers nipples affects hormonal levels and milk production.
25. Answer: 3. Teaching how to express her breasts in a warm shower. Teaching the
client how to express her breasts in a warm shower aids with let-down and will give
temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging
further letdown of milk.
26. Answer: 1. Ask the client to empty her bladder. A full bladder may displace the
uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary
invasive if the woman can void on her own.
27. Answer: 3. Lower than before she became pregnant. PP insulin requirements are
usually significantly lower than pre pregnancy requirements. Occasionally, clients may
require little to no insulin during the first 24 to 48 hours postpartum.
28. Answer: 1. Fundus 1 cm above the umbilicus 1 hour postpartum. Within the first 12
hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The
fundus should be below the umbilicus by PP day 3. The fundus shouldnt be palpated in the
abdomen after day 10.
29. Answer: 3. Multiple gestation. Multiple gestation, breastfeeding, multiparity, and
conditions that cause overdistention of the uterus will increase the intensity of after-pains.
Bottle-feeding and diabetes arent directly associated with increasing severity of afterpains
unless the client has delivered a macrosomic infant.
30. Answer: 2. Days 3 to 10 PP. On the third and fourth PP days, the lochia becomes a
pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type
of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP.
Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may
continue for 2 to 6 weeks PP.
31. Answer: 1. Passive and dependant. During the taking in phase, which usually lasts 1-
3 days, the mother is passive and dependent and expresses her own needs rather than the
neonates needs. The taking hold phase usually lasts from days 3-10 PP. During this stage,
the mother strives for independence and autonomy; she also becomes curious and
interested in the care of the baby and is most ready to learn.
32. Answer: 3. Cervical laceration. Continuous seepage of blood may be due to cervical
or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and
uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than
expected. UTI wont cause vaginal bleeding, although hematuria may be present.
33. Answer: 4. Transitional milk. Transitional milk comes after colostrum and usually lasts
until 2 weeks PP.
34. Answer: 4. Uterine subinvolution. Late postpartum bleeding is often the result of
subinvolution of the uterus. Retained products of conception or infection often cause
subinvolution. Cervical or perineal lacerations can cause an immediate postpartum
hemorrhage. A client with a clotting deficiency may also have an immediate PP hemorrhage
if the deficiency isnt corrected at the time of delivery.
35. Answer: 4. The client should avoid getting pregnant for 3 months after the
vaccine because the vaccine has teratogenic effects. The client must understand that
she must not become pregnant for 3 months after the vaccination because of its potential
teratogenic effects. The rubella vaccine is made from duck eggs so an allergic reaction may
occur in clients with egg allergies. The virus is not transmitted into the breast milk, so clients
may continue to breastfeed after the vaccination. Transient arthralgia and rash are common
adverse effects of the vaccine.
36. Answer: 2. Decrease. The placenta produces the hormone human placental lactogen,
an insulin antagonist. After birth, the placenta, the major source of insulin resistance, is
gone. Insulin needs decrease and women with type 1 diabetes may only need one-half to
two-thirds of the prenatal insulin during the first few PP days.
37. Answer: 4. Mothers with diabetes may breastfeed; insulin requirements may
decrease from breastfeeding. Breastfeeding has an antidiabetogenic effect. Insulin needs
are decreased because carbohydrates are used in milk production. Breastfeeding mothers
are at a higher risk of hypoglycemia in the first PP days after birth because the glucose
levels are lower. Mothers with diabetes should be encouraged to breastfeed.
38. Answer: 4. Taking-in phase. The taking-in phase occurs in the first 24 hours after
birth. The mother is concerned with her own needs and requires support from staff and
relatives. The taking-hold phase occurs when the mother is ready to take responsibility for
her care as well as the infants care. The letting-go phase begins several weeks later, when
the mother incorporates the new infant into the family unit.
39. Answer: 2. Rapid diuresis. In the early PP period, theres an increase in the
glomerular filtration rate and a drop in the progesterone levels, which result in rapid diuresis.
There should be no urinary urgency, though a woman may feel anxious about voiding.
Theres a minimal change in blood pressure following childbirth, and a residual decrease in
GI motility.
40. Answer: 1. The client appears interested in learning about neonatal care. The third
to tenth days of PP care are the taking-hold phase, in which the new mother strives for
independence and is eager for her neonate. The other options describe the phase in which
the mother relives her birth experience.
41. Answer: 3. Urine retention. Urine retention causes a distended bladder to displace the
uterus above the umbilicus and to the side, which prevents the uterus from contracting. The
uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and
vaginal tears can cause PP hemorrhage but are less common occurrences in the PP
period.
42. Answer: 4. Lochia rubra
43. Answer: 4. Multigravidas are at increased risk for uterine atony. Multiple full-term
pregnancies and deliveries result in overstretched uterine muscles that do not contract
efficiently and bleeding may ensue.
44. Answer: 1. Soft, non-tender; colostrum is present. Breasts are essentially
unchanged for the first two to three days after birth. Colostrum is present and may leak from
the nipples.
45. Answer: 3. The expected weight loss immediately after birth averages about 11 to
13 pounds. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within
the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about
9 pounds. Weight loss continues during breastfeeding since fat stores developed during
pregnancy and extra calories consumed are used as part of the lactation process.
46. Answer: 4. Pain in left calf with dorsiflexion of left foot. Responses 1 and 3 are
expected related to circulatory changes after birth. A temperature of 100.4F in the first 24
hours is most likely indicative of dehydration which is easily corrected by increasing oral
fluid intake. The findings in response 4 indicate a positive Homan sign and are suggestive
of thrombophlebitis and should be investigated further.
47. Answer: 2. Massage her fundus. A boggy or soft fundus indicates that uterine atony is
present. This is confirmed by the profuse lochia and passage of clots. The first action would
be to massage the fundus until firm, followed by 3 and 4, especially if the fundus does not
become or remain firm with massage. There is no indication of a distended bladder since
the fundus is midline and below the umbilicus.
48. Answer: 1. Assist the woman into a lateral position with upper leg flexed forward
to facilitate the examination of her perineum. While the supine position is best for
examining the abdomen, the woman should keep her arms at her sides and slightly flex her
knees in order to relax abdominal muscles and facilitate palpation of the fundus. The
bladder should be emptied before the check. A full bladder alters the position of the fundus
and makes the findings inaccurate. Although hands are washed before starting the check,
clean (not sterile) gloves are put on just before the perineum and pad are assessed to
protect from contact with blood and secretions.
49. Answer: 4. Uses the peribottle to rinse upward into her vagina. Responses 1, 2,
and 3 are all appropriate measures. The peribottle should be used in a backward direction
over the perineum. The flow should never be directed upward into the vagina since debris
would be forced upward into the uterus through the still-open cervix.
50. Answer: 3. Massage the fundus every hour for the first 24 hours following
birth. The fundus should be massaged only when boggy or soft. Massaging a firm fundus
could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and
maintain contraction of the uterus and to facilitate healing.
51. Answer: 3. Express a strong need to review events and her behavior during the
process of labor and birth. One week after birth the woman should exhibit behaviors
characteristic of the taking-hold stage as described in response 3. This stage lasts for as
long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of the taking-in stage,
which lasts for the first few days after birth. Response 4 reflects the letting-go stage, which
indicates that psychosocial recovery is complete.
52. Answer: 4. Recognize this as a behavior of the taking-hold stage. Response 1 does
not take into consideration the need for the new mother to be nurtured and have her needs
met during the taking-in stage. The behavior described is typical of this stage and not a
reflection of ineffective attachment unless the behavior persists. Mothers need to
reestablish their own well-being in order to effectively care for their baby.
53. Answer: 1. Having the children choose or make a gift to give to the new baby
upon its arrival home. Special time should be set aside just for the other children without
interruption from the newborn. Someone other than the mother should carry the baby into
the home so she can give full attention to greeting her other children. Children should be
actively involved in the care of the baby according to their ability without overwhelming
them.
54. Answer: 2. Provide time for the mother to reflect on the events of and her
behavior during childbirth. The focus of the taking-in stage is nurturing the new mother by
meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are
met, she is more able to take an active role, not only in her own care but also the care of
her newborn. Women express a need to review their childbirth experience and evaluate
their performance. Short teaching sessions, using written materials to reinforce the content
presented, are a more effective approach.
55. Answer: 3. Placement in a warm environment














NCLEX Sample Questions for Maternal and
Child Health Nursing 1


1. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For
which of the following would the nurse be alert?
a. Endometritis
b. Endometriosis
c. Salpingitis
d. Pelvic thrombophlebitis


2. A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis.
After teaching the client about the purpose for the ultrasound, which of the following client
statements would indicate to the nurse in charge that the client needs further instruction?
a. The ultrasound will help to locate the placenta
b. The ultrasound identifies blood flow through the umbilical cord
c. The test will determine where to insert the needle
d. The ultrasound locates a pool of amniotic fluid


3. While the postpartum client is receiving herapin for thrombophlebitis, which of the following
drugs would the nurse Mica expect to administer if the client develops complications related to
heparin therapy?
a. Calcium gluconate
b. Protamine sulfate
c. Methylegonovine (Methergine)
d. Nitrofurantoin (macrodantin)


4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse
in charge would expect to do which of the following?
a. Turn the neonate every 6 hours
b. Encourage the mother to discontinue breast-feeding
c. Notify the physician if the skin becomes bronze in color
d. Check the vital signs every 2 to 4 hours


5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral
pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the
client, which of the following locations identified by the client as the area of relief would
indicate to the nurse that the teaching was effective?
a. Back
b. Abdomen
c. Fundus
d. Perineum


6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After
explaining self-care measures for
common discomforts of pregnancy, the nurse determines that the client understands the
instructions when she says:
a. Nausea and vomiting can be decreased if I eat a few crackers before arising
b. If I start to leak colostrum, I should cleanse my nipples with soap and water
c. If I have a vaginal discharge, I should wear nylon underwear
d. Leg cramps can be alleviated if I put an ice pack on the area


7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about
infant care. By this time, the nurse expects that the phase of postpartal psychological adaptation
that the client would be in would be termed which of the following?
a. Taking in
b. Letting go
c. Taking hold
d. Resolution


8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the
nurse tells the client that the usual treatment for partial placenta previa is which of the
following?
a. Activity limited to bed rest
b. Platelet infusion
c. Immediate cesarean delivery
d. Labor induction with oxytocin


9. Nurse Julia plans to instruct the postpartum client about methods to prevent breast
engorgement. Which of the following measures would the nurse include in the teaching plan?
a. Feeding the neonate a maximum of 5 minutes per side on the first day
b. Wearing a supportive brassiere with nipple shields
c. Breast-feeding the neonate at frequent intervals
d. Decreasing fluid intake for the first 24 to 48 hours


10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms,
hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the
following reflexes?
a. Startle reflex
b. Babinski reflex
c. Grasping reflex
d. Tonic neck reflex


11. A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower
back aches when she
arrives home from work. The nurse should suggest that the client perform:
a. Tailor sitting
b. Leg lifting
c. Shoulder circling
d. Squatting exercises


12. Which of the following would the nurse in charge do first after observing a 2-cm circle of
bright red bleeding on the diaper of a neonate who just had a circumcision?
a. Notify the neonates pediatrician immediately
b. Check the diaper and circumcision again in 30 minutes
c. Secure the diaper tightly to apply pressure on the site
d. Apply gently pressure to the site with a sterile gauze pad


13. Which of the following would the nurse Sandra most likely expect to find when assessing a
pregnant client with abruption placenta?
a. Excessive vaginal bleeding
b. Rigid, boardlike abdomen
c. Titanic uterine contractions
d. Premature rupture of membranes


14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse
observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of
the following would be the nurses most appropriate action?
a. Note the fetal heart rate patterns
b. Notify the physician immediately
c. Administer oxygen at 6 liters by mask
d. Have the client pant-blow during the contractions


15. A client tells the nurse, I think my baby likes to hear me talk to him. When discussing
neonates and stimulation with sound, which of the following would the nurse include as a means
to elicit the best response?
a. High-pitched speech with tonal variations
b. Low-pitched speech with a sameness of tone
c. Cooing sounds rather than words
d. Repeated stimulation with loud sounds


16. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her
cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?
a. Active phase
b. Latent phase
c. Expulsive phase
d. Transitional phase


17. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How
should the nurse respond?
a. Yes, it produces no adverse effect.
b. No, it can initiate premature uterine contractions.
c. No, it can promote sodium retention.
d. No, it can lead to increased absorption of fat-soluble vitamins.


18. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal
bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis
for this patient?
a. Knowledge deficit
b. Fluid volume deficit
c. Anticipatory grieving
d. Pain


19. Immediately after a delivery, the nurse-midwife assesses the neonates head for signs of
molding. Which factors determine the type of molding?
a. Fetal body flexion or extension
b. Maternal age, body frame, and weight
c. Maternal and paternal ethnic backgrounds
d. Maternal parity and gravidity


20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal
monitoring (EFM) device. What must occur before the internal EFM can be applied?
a. The membranes must rupture
b. The fetus must be at 0 station
c. The cervix must be dilated fully
d. The patient must receive anesthesia


21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is
in early part of the first stage of labor. Her pain is likely to be most intense:
a. Around the pelvic girdle
b. Around the pelvic girdle and in the upper arms
c. Around the pelvic girdle and at the perineum
d. At the perineum


22. A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use
may increase the patients risk for:
a. Endometriosis
b. Female hypogonadism
c. Premenstrual syndrome
d. Tubal or ectopic pregnancy


23. A patient with pregnancy-induced hypertension probably exhibits which of the following
symptoms?
a. Proteinuria, headaches, vaginal bleeding
b. Headaches, double vision, vaginal bleeding
c. Proteinuria, headaches, double vision
d. Proteinuria, double vision, uterine contractions


24. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith
orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patients fluid
intake and output closely during oxytocin administration?
a. Oxytoxin causes water intoxication
b. Oxytocin causes excessive thirst
c. Oxytoxin is toxic to the kidneys
d. Oxytoxin has a diuretic effect


25. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to
prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cools incubator walls
d. Cool room temperature


26. After administering bethanechol to a patient with urine retention, the nurse in charge
monitors the patient for adverse effects. Which is most likely to occur?
a. Decreased peristalsis
b. Increase heart rate
c. Dry mucous membranes
d. Nausea and Vomiting


27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the
shortest but most difficult part of this stage?
a. Active phase
b. Complete phase
c. Latent phase
d. Transitional phase


28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her
discomfort, the nurse should suggest that she:
a. Apply warm compresses to her nipples just before feedings
b. Lubricate her nipples with expressed milk before feeding
c. Dry her nipples with a soft towel after feedings
d. Apply soap directly to her nipples, and then rinse


29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse
should tell the patient that she can expect to feel the fetus move at which time?
a. Between 10 and 12 weeks gestation
b. Between 16 and 20 weeks gestation
c. Between 21 and 23 weeks gestation
d. Between 24 and 26 weeks gestation


30. Normal lochial findings in the first 24 hours post-delivery include:
a. Bright red blood
b. Large clots or tissue fragments
c. A foul odor
d. The complete absence of lochia





















1. Answer A. Endometritis is an infection of the uterine lining and can occur
after prolonged rupture of membranes. Endometriosis does not occur after a
strong labor and prolonged rupture of membranes. Salpingitis is a tubal
infection and could occur if endometritis is not treated. Pelvic
thrombophlebitis involves a clot formation but it is not a complication of
prolonged rupture of membranes.

2. Answer B. Before amniocentesis, a routine ultrasound is valuable in
locating the placenta, locating a pool of amniotic fluid, and showing the
physician where to insert the needle. Color Doppler imaging ultrasonography
identifies blood flow through the umbilical cord. A routine ultrasound does
not accomplish this.

3. Answer B. Protamine sulfate is a heparin antagonist given intravenously
to counteract bleeding complications cause by heparin overdose.

4. Answer D. While caring for an infant receiving phototherapy for
treatment of jaundice, vital signs are checked every 2 to 4 hours because
hyperthermia can occur due to the phototherapy lights.

5. Answer D. A bilateral pudental block is used for vaginal deliveries to
relieve pain primarily in the perineum and vagina. Pudental block anesthesia
is adequate for episiotomy and its repair.

6. Answer A. Eating dry crackers before arising can assist in decreasing the
common discomfort of nausea and vomiting. Avoiding strong food odors and
eating a high-protein snack before bedtime can also help.

7. Answer C. Beginning after completion of the taking-in phase, the taking-
hold phase lasts about 10 days. During this phase, the client is concerned
with her need to resume control of all facets of her life in a competent
manner. At this time, she is ready to learn self-care and infant care skills.

8. Answer A. Treatment of partial placenta previa includes bed rest,
hydration, and careful monitoring of the clients bleeding.

9. Answer C. Prevention of breast engorgement is key. The best technique
is to empty the breast regularly with feeding. Engorgement is less likely
when the mother and neonate are together, as in single room maternity care
continuous rooming in, because nursing can be done conveniently to meet
the neonates and mothers needs.

10. Answer A. The Moro, or startle, reflex occurs when the neonate
responds to stimuli by extending the arms, hands open, and then moving the
arms in an embracing motion. The Moro reflex, present at birth, disappears
at about age 3 months.

11. Answer A. Tailor sitting is an excellent exercise that helps to strengthen
the clients back muscles and also prepares the client for the process of
labor. The client should be encouraged to rest periodically during the day and
avoid standing or sitting in one position for a long time.

12. Answer D. If bleeding occurs after circumcision, the nurse should first
apply gently pressure on the area with sterile gauze. Bleeding is not common
but requires attention when it occurs.

13. Answer B. The most common assessment finding in a client with
abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as
a sharp stabbing sensation high in the uterine fundus with the initial
separation, also is common.

14. Answer B. The nurse should contact the physician immediately because
the client is most likely experiencing hypotonic uterine contractions. These
contractions tend to be painful but ineffective. The usual treatment is
oxytocin augmentation, unless cephalopelvic disproportion exists.

15. Answer A. Providing stimulation and speaking to neonates is important.
Some authorities believe that speech is the most important type of sensory
stimulation for a neonate. Neonates respond best to speech with tonal
variations and a high-pitched voice. A neonate can hear all sound louder than
about 55 decibels.

16. Answer D. The transitional phase of labor extends from 8 to 10 cm; it is
the shortest but most difficult and intense for the patient. The latent phase
extends from 0 to 3 cm; it is mild in nature. The active phase extends form 4
to 7 cm; it is moderate for the patient. The expulsive phase begins
immediately after the birth and ends with separation and expulsion of the
placenta.

17. Answer B. Castor oil can initiate premature uterine contractions in
pregnant women. It also can produce other adverse effects, but it does not
promote sodium retention. Castor oils is not known to increase absorption of
fat-soluble vitamins, although laxatives in general may decrease absorption if
intestinal motility is increased.

18. Answer B. If bleeding and cloth are excessive, this patient may become
hypovolemic. Pad count should be instituted. Although the other diagnoses
are applicable to this patient, they are not the primary diagnosis.

19. Answer A. Fetal attitudethe overall degree of body flexion or
extensiondetermines the type of molding in the head a neonate. Molding is
not influence by maternal age, body frame, weight, parity, or gravidity or by
maternal and paternal ethnic backgrounds.

20. Answer A. Internal EFM can be applied only after the patients
membranes have ruptures, when the fetus is at least at the -1 station, and
when the cervix is dilated at least 2 cm. although the patient may receive
anesthesia, it is not required before application of an internal EFM device.

21. Answer A.During most of the first stage of labor, pain centers around
the pelvic girdle. During the late part of this stage and the early part of the
second stage, pain spreads to the upper legs and perineum. During the late
part of the second stage and during childbirth, intense pain occurs at the
perineum. Upper arm pain is not common during ant stage of labor.

22. Answer D. Women taking the minipill have a higher incidence of tubal
and ectopic pregnancies, possibly because progestin slows ovum transport
through the fallopian tubes. Endometriosis, female hypogonadism, and
premenstrual syndrome are not associated with progestin-only oral
contraceptives.

23. Answer C. A patient with pregnancy-induced hypertension complains of
headache, double vision, and sudden weight gain. A urine specimen reveals
proteinuria. Vaginal bleeding and uterine contractions are not associated with
pregnancy-induces hypertension.

24. Answer A. The nurse should monitor fluid intake and output because
prolonged oxytoxin infusion may cause severe water intoxication, leading to
seizures, coma, and death. Excessive thirst results form the work of labor
and limited oral fluid intakenot oxytoxin. Oxytoxin has no nephrotoxic or
diuretic effects. In fact, it produces an antidiuretic effect.

25. Answer C. Common source of radiant heat loss includes cool incubator
walls and windows. Low room humidity promotes evaporative heat loss.
When the skin directly contacts a cooler object, such as a cold weight scale,
conductive heat loss may occur. A cool room temperature may lead to
convective heat loss.

26. Answer D. Bethanechol will increase GI motility, which may cause
nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is
increased rather than decreased. With high doses of bethanechol,
cardiovascular responses may include vasodilation, decreased cardiac rate,
and decreased force of cardiac contraction, which may cause hypotension.
Salivation or sweating may gently increase.

27. Answer D. The transitional phase, which lasts 1 to 3 hours, is the
shortest but most difficult part of the first stage of labor. This phase is
characterized by intense uterine contractions that occur every 1 to 2
minutes and last 45 to 90 seconds. The active phase lasts 4 to 6 hours; it
is characterized by contractions that starts out moderately intense, grow
stronger, and last about 60 seconds. The complete phase occurs during the
second, not first, stage of labor. The latent phase lasts 5 to 8 hours and is
marked by mild, short, irregular contractions.

28. Answer B. Measures that help relieve nipple soreness in a breast-
feeding patient include lubrication the nipples with a few drops of expressed
milk before feedings, applying ice compresses just before feeding, letting the
nipples air dry after feedings, and avoiding the use of soap on the nipples.

29. Answer B. A pregnant woman usually can detect fetal movement
(quickening) between 16 and 20 weeks gestation. Before 16 weeks, the
fetus is not developed enough for the woman to detect movement. After 20
weeks, the fetus continues to gain weight steadily, the lungs start to produce
surfactant, the brain is grossly formed, and myelination of the spinal cord
begins.

30. Answer A. Lochia should never contain large clots, tissue fragments, or
membranes. A foul odor may signal infection, as may absence of lochia.






NCLEX Sample Questions for Maternal and
Child Health Nursing 2
1. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The
client states that she is in labor, and says she attended the hospital clinic for prenatal care. Which
question should the nurse ask her first?
a. Do you have any chronic illness?
b. Do you have any allergies?
c. What is your expected due date?
d. Who will be with you during labor?


2. A patient is in the second stage of labor. During this stage, how frequently should the nurse in
charge assess her uterine contractions?
a. Every 5 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every 60 minutes


3. A patient is in last trimester of pregnancy. Nurse Jane should instruct her to notify her primary
health care provider immediately if she notices:
a. Blurred vision
b. Hemorrhoids
c. Increased vaginal mucus
d. Shortness of breath on exertion


4. The nurse in charge is reviewing a patients prenatal history. Which finding indicates a genetic
risk factor?
a. The patient is 25 years old
b. The patient has a child with cystic fibrosis
c. The patient was exposed to rubella at 36 weeks gestation
d. The patient has a history of preterm labor at 32 weeks gestation


5. A adult female patient is using the rhythm (calendar-basal body temperature) method of
family planning. In this method, the unsafe period for sexual intercourse is indicated by;
a. Return preovulatory basal body temperature
b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle
c. 3 full days of elevated basal body temperature and clear, thin cervical mucus
d. Breast tenderness and mittelschmerz


6. During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal
movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse
in charge should instruct the client to push the control button at which time?
a. At the beginning of each fetal movement
b. At the beginning of each contraction
c. After every three fetal movements
d. At the end of fetal movement


7. When evaluating a clients knowledge of symptoms to report during her pregnancy, which
statement would indicate to the nurse in charge that the client understands the information given
to her?
a. Ill report increased frequency of urination.
b. If I have blurred or double vision, I should call the clinic immediately.
c. If I feel tired after resting, I should report it immediately.
d. Nausea should be reported immediately.


8. When assessing a client during her first prenatal visit, the nurse discovers that the client had a
reduction mammoplasty. The mother indicates she wants to breast-feed. What information
should the nurse give to this mother regarding breast-feeding success?
a. Its contraindicated for you to breast-feed following this type of surgery.
b. I support your commitment; however, you may have to supplement each feeding with
formula.
c. You should check with your surgeon to determine whether breast-feeding would be
possible.
d. You should be able to breast-feed without difficulty.


9. Following a precipitous delivery, examination of the clients vagina reveals a fourth-degree
laceration. Which of the following would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours
b. Instructing the client to use two or more peripads to cushion the area
c. Instructing the client on the use of sitz baths if ordered
d. Instructing the client about the importance of perineal (Kegel) exercises


10. A client makes a routine visit to the prenatal clinic. Although shes 14 weeks pregnant, the
size of her uterus approximates that in an 18- to 20-week pregnancy. Dr. Diaz diagnoses
gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography
to reveal:
a. an empty gestational sac.
b. grapelike clusters.
c. a severely malformed fetus.
d. an extrauterine pregnancy.


11. After completing a second vaginal examination of a client in labor, the nurse-midwife
determines that the fetus is in the right occiput anterior position and at 1 station. Based on these
findings, the nurse-midwife knows that the fetal presenting part is:
a. 1 cm below the ischial spines.
b. directly in line with the ischial spines.
c. 1 cm above the ischial spines.
d. in no relationship to the ischial spines.


12. Which of the following would be inappropriate to assess in a mother whos breast-feeding?
a. The attachment of the baby to the breast.
b. The mothers comfort level with positioning the baby.
c. Audible swallowing.
d. The babys lips smacking


13. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done
to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to
detect fetal anomalies?
a. Amniocentesis.
b. Chorionic villi sampling.
c. Fetoscopy.
d. Ultrasound


14. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the
health of her fetus. Her BPP score is 8. What does this score indicate?
a. The fetus should be delivered within 24 hours.
b. The client should repeat the test in 24 hours.
c. The fetus isnt in distress at this time.
d. The client should repeat the test in 1 week.


15. A client whos 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the
clients preparation for parenting, the nurse might ask which question?
a. Are you planning to have epidural anesthesia?
b. Have you begun prenatal classes?
c. What changes have you made at home to get ready for the baby?
d. Can you tell me about the meals you typically eat each day?


16. A client whos admitted to labor and delivery has the following assessment findings: gravida
2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex
+4 station. Which of the following would be the priority at this time?
a. Placing the client in bed to begin fetal monitoring.
b. Preparing for immediate delivery.
c. Checking for ruptured membranes.
d. Providing comfort measures.


17. Nurse Roy is caring for a client in labor. The external fetal monitor shows a pattern of
variable decelerations in fetal heart rate. What should the nurse do first?
a. Change the clients position.
b. Prepare for emergency cesarean section.
c. Check for placenta previa.
d. Administer oxygen.


18. The nurse in charge is caring for a postpartum client who had a vaginal delivery with a
midline episiotomy. Which nursing diagnosis takes priority for this client?
a. Risk for deficient fluid volume related to hemorrhage
b. Risk for infection related to the type of delivery
c. Pain related to the type of incision
d. Urinary retention related to periurethral edema


19. Which change would the nurse identify as a progressive physiological change in postpartum
period?
a. Lactation
b. Lochia
c. Uterine involution
d. Diuresis


20. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal
bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing
the clients complaint of vaginal bleeding?
a. Placenta previa
b. Abruptio placentae
c. Ectopic pregnancy
d. Spontaneous abortion


21. A client with type 1 diabetes mellitus whos a multigravida visits the clinic at 27 weeks
gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes
mellitus:
a. Weekly fetal movement counts are made by the mother.
b. Contraction stress testing is performed weekly.
c. Induction of labor is begun at 34 weeks gestation.
d. Nonstress testing is performed weekly until 32 weeks gestation


22. When administering magnesium sulfate to a client with preeclampsia, the nurse understands
that this drug is given to:
a. Prevent seizures
b. Reduce blood pressure
c. Slow the process of labor
d. Increase dieresis


23. Whats the approximate time that the blastocyst spends traveling to the uterus for
implantation?
a. 2 days
b. 7 days
c. 10 days
d. 14 weeks


24. After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which
of the following purposes stated by the client would indicate to the nurse that the teaching was
effective?
a. Shortens the second stage of labor
b. Enlarges the pelvic inlet
c. Prevents perineal edema
d. Ensures quick placenta delivery


25. A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and
admits to cocaine use during the pregnancy. Which of the following persons must the nurse
notify?
a. Nursing unit manager so appropriate agencies can be notified
b. Head of the hospitals security department
c. Chaplain in case the fetus dies in utero
d. Physician who will attend the delivery of the infant


26. When preparing a teaching plan for a client who is to receive a rubella vaccine during the
postpartum period, the nurse in charge should include which of the following?
a. The vaccine prevents a future fetus from developing congenital anomalies
b. Pregnancy should be avoided for 3 months after the immunization
c. The client should avoid contact with children diagnosed with rubella
d. The injection will provide immunity against the 7-day measles.


27. A client with eclampsia begins to experience a seizure. Which of the following would the
nurse in charge do first?
a. Pad the side rails
b. Place a pillow under the left buttock
c. Insert a padded tongue blade into the mouth
d. Maintain a patent airway


28. While caring for a multigravida client in early labor in a birthing center, which of the
following foods would be best if the client requests a snack?
a. Yogurt
b. Cereal with milk
c. Vegetable soup
d. Peanut butter cookies


29. The multigravida mother with a history of rapid labor who us in active labor calls out to the
nurse, The baby is coming! which of the following would be the nurses first action?
a. Inspect the perineum
b. Time the contractions
c. Auscultate the fetal heart rate
d. Contact the birth attendant


30. While assessing a primipara during the immediate postpartum period, the nurse in charge
plans to use both hands to assess the clients fundus to:
a. Prevent uterine inversion
b. Promote uterine involution
c. Hasten the puerperium period
d. Determine the size of the fundus






















1. Answer C. When obtaining the history of a patient who may be in labor, the
nurses highest priority is to determine her current status, particularly her
due date, gravidity, and parity. Gravidity and parity affect the duration of
labor and the potential for labor complications. Later, the nurse should ask
about chronic illness, allergies, and support persons.

2. Answer B. During the second stage of labor, the nurse should assess the
strength, frequency, and duration of contraction every 15 minutes. If
maternal or fetal problems are detected, more frequent monitoring is
necessary. An interval of 30 to 60 minutes between assessments is too long
because of variations in the length and duration of patients labor.

3. Answer A. Blurred vision of other visual disturbance, excessive weight
gain, edema, and increased blood pressure may signal severe preeclampsia.
This condition may lead to eclampsia, which has potentially serious
consequences for both the patient and fetus. Although hemorrhoids may be a
problem during pregnancy, they do not require immediate attention.
Increased vaginal mucus and dyspnea on exertion are expected as pregnancy
progresses.

4. Answer B. Cystic fibrosis is a recessive trait; each offspring has a one in
four chance of having the trait or the disorder. Maternal age is not a risk
factor until age 35, when the incidence of chromosomal defects increases.
Maternal exposure to rubella during the first trimester may cause congenital
defects. Although a history or preterm labor may place the patient at risk for
preterm labor, it does not correlate with genetic defects.

5. Answer C. Ovulation (the period when pregnancy can occur) is
accompanied by a basal body temperature increase of 0.7 degrees F to 0.8
degrees F and clear, thin cervical mucus. A return to the preovulatory body
temperature indicates a safe period for sexual intercourse. A slight rise in
basal temperature early in the cycle is not significant. Breast tenderness and
mittelschmerz are not reliable indicators of ovulation.

6. Answer A. An NST assesses the FHR during fetal movement. In a healthy
fetus, the FHR accelerates with each movement. By pushing the control
button when a fetal movement starts, the client marks the strip to allow easy
correlation of fetal movement with the FHR. The FHR is assessed during
uterine contractions in the oxytocin contraction test, not the NST. Pushing
the control button after every three fetal movements or at the end of fetal
movement wouldnt allow accurate comparison of fetal movement and FHR
changes.

7. Answer B. Blurred or double vision may indicate hypertension or
preeclampsia and should be reported immediately. Urinary frequency is a
common problem during pregnancy caused by increased weight pressure on
the bladder from the uterus. Clients generally experience fatigue and nausea
during pregnancy.

8. Answer B. Recent breast reduction surgeries are done in a way to protect
the milk sacs and ducts, so breast-feeding after surgery is possible. Still, its
good to check with the surgeon to determine what breast reduction
procedure was done. There is the possibility that reduction surgery may have
decreased the mothers ability to meet all of her babys nutritional needs,
and some supplemental feeding may be required. Preparing the mother for
this possibility is extremely important because the clients psychological
adaptation to mothering may be dependent on how successfully she breast-
feeds.

9. Answer B. Using two or more peripads would do little to reduce the pain
or promote perineal healing. Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree
laceration.

10. Answer B. In a client with gestational trophoblastic disease, an
ultrasound performed after the 3rd month shows grapelike clusters of
transparent vesicles rather than a fetus. The vesicles contain a clear fluid and
may involve all or part of the decidual lining of the uterus. Usually no embryo
(and therefore no fetus) is present because it has been absorbed. Because
there is no fetus, there can be no extrauterine pregnancy. An extrauterine
pregnancy is seen with an ectopic pregnancy.

11. Answer C. Fetal station the relationship of the fetal presenting part to
the maternal ischial spines is described in the number of centimeters
above or below the spines. A presenting part above the ischial spines is
designated as 1, 2, or 3. A presenting part below the ischial spines, as
+1, +2, or +3.

12. Answer D. Assessing the attachment process for breast-feeding should
include all of the answers except the smacking of lips. A baby whos
smacking his lips isnt well attached and can injure the mothers nipples.

13. Answer D. Ultrasound is used between 18 and 40 weeks gestation to
identify normal fetal growth and detect fetal anomalies and other problems.
Amniocentesis is done during the third trimester to determine fetal lung
maturity. Chorionic villi sampling is performed at 8 to 12 weeks gestation to
detect genetic disease. Fetoscopy is done at approximately 18 weeks
gestation to observe the fetus directly and obtain a skin or blood sample.

14. Answer C. The BPP evaluates fetal health by assessing five variables:
fetal breathing movements, gross body movements, fetal tone, reactive fetal
heart rate, and qualitative amniotic fluid volume. A normal response for each
variable receives 2 points; an abnormal response receives 0 points. A score
between 8 and 10 is considered normal, indicating that the fetus has a low
risk of oxygen deprivation and isnt in distress. A fetus with a score of 6 or
lower is at risk for asphyxia and premature birth; this score warrants detailed
investigation. The BPP may or may not be repeated if the score isnt within
normal limits.

15. Answer C. During the third trimester, the pregnant client typically
perceives the fetus as a separate being. To verify that this has occurred, the
nurse should ask whether she has made appropriate changes at home such
as obtaining infant supplies and equipment. The type of anesthesia planned
doesnt reflect the clients preparation for parenting. The client should have
begun prenatal classes earlier in the pregnancy. The nurse should have
obtained dietary information during the first trimester to give the client time
to make any necessary changes.

16. Answer B. This question requires an understanding of station as part of
the intrapartal assessment process. Based on the clients assessment
findings, this client is ready for delivery, which is the nurses top priority.
Placing the client in bed, checking for ruptured membranes, and providing
comfort measures could be done, but the priority here is immediate delivery.

17. Answer A. Variable decelerations in fetal heart rate are an ominous sign,
indicating compression of the umbilical cord. Changing the clients position
from supine to side-lying may immediately correct the problem. An
emergency cesarean section is necessary only if other measures, such as
changing position and amnioinfusion with sterile saline, prove unsuccessful.
Administering oxygen may be helpful, but the priority is to change the
womans position and relieve cord compression.

18. Answer A. Hemorrhage jeopardizes the clients oxygen supply the
first priority among human physiologic needs. Therefore, the nursing
diagnosis of Risk for deficient fluid volume related to hemorrhage takes
priority over diagnoses of Risk for infection, Pain, and Urinary retention.

19. Answer A. Lactation is an example of a progressive physiological change
that occurs during the postpartum period.

20. Answer B. The major maternal adverse reactions from cocaine use in
pregnancy include spontaneous abortion first, not third, trimester abortion
and abruption placentae.

21. Answer D. For most clients with type 1 diabetes mellitus, nonstress
testing is done weekly until 32 weeks gestation and twice a week to assess
fetal well-being.

22. Answer A. The chemical makeup of magnesium is similar to that of
calcium and, therefore, magnesium will act like calcium in the body. As a
result, magnesium will block seizure activity in a hyper stimulated neurologic
system by interfering with signal transmission at the neuromascular
junction.

23. Answer B. The blastocyst takes approximately 1 week to travel to the
uterus for implantation.

24. Answer A. An episiotomy serves several purposes. It shortens the
second stage of labor, substitutes a clean surgical incision for a tear, and
decreases undue stretching of perineal muscles. An episiotomy helps prevent
tearing of the rectum but it does not necessarily relieves pressure on the
rectum. Tearing may still occur.

25. Answer D. The fetus of a cocaine-addicted mother is at risk for hypoxia,
meconium aspiration, and intrauterine growth retardation (IUGR). Therefore,
the nurse must notify the physician of the clients cocaine use because this
knowledge will influence the care of the client and neonate. The information
is used only in relation to the clients care.

26. Answer B. After administration of rubella vaccine, the client should be
instructed to avoid pregnancy for at least 3 months to prevent the possibility
of the vaccines toxic effects to the fetus.

27. Answer D. The priority for the pregnant client having a seizure is to
maintain a patent airway to ensure adequate oxygenation to the mother and
the fetus. Additionally, oxygen may be administered by face mask to prevent
fetal hypoxia.

28. Answer A. In some birth settings, intravenous therapy is not used with
low-risk clients. Thus, clients in early labor are encouraged to eat healthy
snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent
source of calcium and riboflavin, is soft and easily digested. During
pregnancy, gastric emptying time is delayed. In most hospital settings,
clients are allowed only ice chips or clear liquids.

29. Answer A. When the client says the baby is coming, the nurse should
first inspect the perineum and observe for crowning to validate the clients
statement. If the client is not delivering precipitously, the nurse can calm her
and use appropriate breathing techniques.

30. Answer A. Using both hands to assess the fundus is useful for the
prevention of uterine inversion.




























Growth and Development NCLEX
Questions


1. The nurse is caring for the mother of a newborn. The nurse recognizes that the mother needs
more teaching regarding cord care because she
a. keeps the cord exposed to the air.
b. washes her hands before sponge bathing her baby.
c. washes the cord and surrounding area well with water at each diaper change.
d. checks it daily for bleeding and drainage.


2. A client telephones the clinic to ask about a home pregnancy test she used this morning. The
nurse understands that the presence of which hormone strongly suggests a woman is pregnant?
a. Estrogen
b. HCG
c. Alpha-fetoprotein
d. Progesterone


3. The nurse is assessing a six-month-old child. Which developmental skills are normal and
should be expected?
a. Speaks in short sentences.
b. Sits alone.
c. Can feed self with a spoon.
d. Pulling up to a standing position.


4. While teaching a 10 year-old child about their impending heart surgery, the nurse should
a. Provide a verbal explanation just prior to the surgery
b. Provide the child with a booklet to read about the surgery
c. Introduce the child to another child who had heart surgery three days ago
d. Explain the surgery using a model of the heart


5. When caring for an elderly client it is important to keep in mind the changes in color vision
that may occur. What colors are apt to be most difficult for the elderly to distinguish?
a. Red and blue.
b. Blue and gold.
c. Red and green.
d. Blue and green.


6. While giving nursing care to a hospitalized adolescent, the nurse should be aware that the
MAJOR threat felt by the hospitalized adolescent is
a. Pain management
b. Restricted physical activity
c. Altered body image
d. Separation from family


7. A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes for eight
hours and is 4 cm dilated. Since she is a candidate for infection, the nurse should include which
of the following in the care plan?
a. Universal precautions.
b. Oxytocin administration.
c. Frequent temperature monitoring.
d. More frequent vaginal examinations.


8. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic. The
mother asks the nurse to explain the purpose of the test. The BEST response is to tell her that the
test
a. Measures potential intelligence
b. Assesses a childs development
c. Evaluates psychological responses
d. Diagnoses specific problems


9. A 27-year-old woman has Type I diabetes mellitus. She and her husband want to have a child
so they consulted her diabetologist, who gave her information on pregnancy and diabetes. Of
primary importance for the diabetic woman who is considering pregnancy should be
a. a review of the dietary modifications that will be necessary.
b. early prenatal medical care.
c. adoption instead of conception.
d. understanding that this is a major health risk to the mother.


10. The nurse is planning care for an 18 month-old child. Which of the following should be
included the in the childs care?
a. Hold and cuddle the child often
b. Encourage the child to feed himself finger food
c. Allow the child to walk independently on the nursing unit
d. Engage the child in games with other children


11. The nurse in an infertility clinic is discussing the treatment routine. The nurse advises the
couple that the major stressor for couples being treated for infertility is usually
a. having to tell their families.
b. the cost of the interventions.
c. the inconvenience of multiple tests.
d. the right scheduling of sexual intercourse.


12. The nurse is assessing a four month-old infant. The nurse would anticipate finding that the
infant would be able to
a. Hold a rattle
b. Bang two blocks
c. Drink from a cup
d. Wave bye-bye


13. The nurse is evaluating a new mother feeding her newborn. Which observation indicates the
mother understands proper feeding methods for her newborn?
a. Holding the bottle so the nipple is always filled with formula.
b. Allowing her seven pound baby to sleep after taking 1 ounces from the bottle.
c. Burping the baby every ten minutes during the feeding.
d. Warming the formula bottle in the microwave for 15 seconds and giving it directly to the
baby.


14. The nurse is caring for a pregnant client. The client asks how the doctor could tell she was
pregnant just by looking inside. The nurse tells her the most likely explanation is that she had a
positive Chadwicks sign, which is a
a. Bluish coloration of the cervix and vaginal walls
b. Pronounced softening of the cervix
c. Clot of very thick mucous that obstructs the cervical canal
d. Slight rotation of the uterus to the right


15. When caring for an elderly client it is important to keep in mind the changes in color vision
that may occur. What colors are apt to be most difficult for the elderly to distinguish?
a. Red and blue.
b. Blue and gold.
c. Red and green.
d. Blue and green.


16. The nurses FIRST step in nutritional counseling/teaching for a pregnant woman is to
a. Teach her how to meet the needs of self and her family
b. Explain the changes in diet necessary for pregnant women
c. Question her understanding and use of the food pyramid
d. Conduct a diet history to determine her normal eating routines


17. A woman who is six months pregnant is seen in antepartal clinic. She states she is having
trouble with constipation. To minimize this condition, the nurse should instruct her to
a. increase her fluid intake to three liters/day.
b. request a prescription for a laxative from her physician.
c. stop taking iron supplements.
d. take two tablespoons of mineral oil daily.


18. The nurse is observing children playing in the hospital playroom. She would expect to see 4
year-old children playing
a. Competitive board games with older children
b. With their own toys along side with other children
c. Alone with hand held computer games
d. Cooperatively with other preschoolers


19. The nurse is caring for residents in a long term care setting for the elderly. Which of the
following activities will be MOST effective in meeting the growth and development needs for
persons in this age group?
a. Aerobic exercise classes
b. Transportation for shopping trips
c. Reminiscence groups
d. Regularly scheduled social activities


20. A pregnant woman is advised to alter her diet during pregnancy by increasing her protein and
Vitamin C to meet the needs of the growing fetus. Which diet BEST meets the clients needs?
a. Scrambled egg, hash browned potatoes, half-glass of buttermilk, large nectarine
b. 3oz. chicken, C. corn, lettuce salad, small banana
c. 1 C. macaroni, C. peas, glass whole milk, medium pear
d. Beef, C. lima beans, glass of skim milk, C. strawberries


1. Answer C. Exposure to air helps dry the cord. Good hand washing is the
prime mechanism for preventing infection. Washing the surrounding area
is fine but wetting the cord keeps it moist and predisposes it to infection.
It is important to check for complications of bleeding and drainage that
might occur.

2. Answer B. Human chorionic gonadotropin (HCG) is the biologic marker
on which pregnancy tests are based. Reliability is about 98%, but the test
does not positively confirm pregnancy.

3. Answer B. The child develops language skills between the ages of one
and three. A six-month-old child is learning to sit alone. The child begins
to use a spoon at 12-15 months of age. The baby pulls himself to a
standing position about ten months of age.

4. Answer D. According to Piaget, the school age child is in the concrete
operations stage of cognitive development. Using something concrete, like
a model will help the child understand the explanation of the heart
surgery.

5. Answer D. The elderly are better able to distinguish between red and
blue because of the difference in wavelengths. The elderly are better able
to distinguish between blue and gold because of the difference in
wavelengths. The elderly are better able to distinguish between red and
green because of the difference in wavelengths. Red and green color
blindness is an inherited disorder that is unrelated to age. The elderly
have poor blue-green discrimination. The effects of age are greatest on
short wavelengths. These changes are related to the yellowing of the lens
with age.

6. Answer C. The hospitalized adolescent may see each of these as a
threat, but the major threat that they feel when hospitalized is the fear of
altered body image, because of the emphasis on physical appearance.

7. Answer C. Universal precautions are necessary for all clients but a
specific assessment of the clients temperature will give an indication the
client is becoming infected. Oxytocin may be needed to induce labor if it is
not progressing, but it is not done initially.Temperature elevation will
indicate beginning infection. This is the most important measure to help
assess the client for infections, since the lost mucous plug and the
ruptured membranes increase the potential for ascending bacteria from
the reproductive tract. This will infect the fetus, membranes, and uterine
cavity. More frequent vaginal examinations are not recommended, as
frequent vaginal exams can increase chances of infection.

8. Answer B. The Denver Developmental Test II is a screening test to
assess children from birth through 6 years in personal/social, fine motor
adaptive, language and gross motor development. A child experiences the
fun of play during the test.

9. Answer B. A review of dietary modifications is important once the
woman is pregnant. However, it is not of primary importance when
considering pregnancy. Pregnancy makes metabolic control of diabetes
more difficult. It is essential that the client start prenatal care early so
that potential complications can be controlled or minimized by the efforts
of the client and health care team. The alternative of adoption is not
necessary just because the client is a diabetic. Many diabetic women have
pregnancies with successful outcomes if they receive good care. While
there is some risk to the pregnant diabetic woman, it is not considered a
major health risk. The greater risk is to the fetus.

10. Answer B. According to Erikson, the toddler is in the stage of
autonomy versus shame and doubt. The nurse should encourage
increasingly independent activities of daily living.

11. Answer D. Having to tell families may also be a factor contributing to
stress but is not the major stressor. Cost may also be a contributing
factor to stress but is not usually the major factor. The inconvenience of
multiple tests may also be a factor contributing to stress but is not usually
the major factor. Sexual activity "on demand is the major cause of stress
for most infertile couples.

12. Answer A. The age at which a baby will develop the skill of grasping
a toy with help is 4 to 6 months.

13. Answer A. Holding the bottle so the nipple is always filled with
formula prevents the baby from sucking air. Sucking air can cause gastric
distention and intestinal gas pains. A seven-pound baby should be getting
50 calories per pound: 350 calories per day. Standardized formulas have
20 calories per ounce. This seven-pound baby needs 17.5 ounces per day.
17.5 ounces per day divided by 6-8 feedings equals 2-3 ounces per
feeding. A normal newborn without feeding problems could be burped
halfway through the feeding and again at the end. If burping needs to be
at intervals, it should be done by ounces or half ounces, not minutes.
Microwaving is not recommended as a method of warming due to the
uneven heating of the formula. If used, the formula should be shaken
after warming and the temperature then checked with a drop on the
wrist. The recommended method of warming is to place the bottle in a
pan of hot water to warm, and then check the temperature on the wrist
before feeding.

14. Answer A. Chadwicks sign is a bluish-purple coloration of the cervix
and vaginal walls, occurring at 4 weeks of pregnancy, that is caused by
vasocongestion.

15. Answer D. The elderly are better able to distinguish between red and
blue because of the difference in wavelengths. Red and green color
blindness is an inherited disorder that is unrelated to age. The elderly
have poor blue-green discrimination. The effects of age are greatest on
short wavelengths. These changes are related to the yellowing of the lens
with age.

16. Answer D. Assessment is always the first step in planning teaching
for any client.

17. Answer A. In pregnancy, constipation results from decreased gastric
motility and increased water reabsorption in the colon caused by
increased levels of progesterone. Increasing fluid intake to three liters a
day will help prevent constipation. The client should increase fluid intake,
increase roughage in the diet, and increase exercise as tolerated.
Laxatives are not recommended because of the possible development of
laxative dependence or abdominal cramping. Iron supplements are
necessary during pregnancy, as ordered, and should not be discontinued.
The client should increase fluid intake, increase roughage in the diet, and
increase exercise as tolerated. Laxatives are not recommended because
of the possible development of laxative dependence or abdominal
cramping. Mineral oil is especially bad to use as a laxative because it
decreases the absorption of fat-soluble vitamins (A, D, E, K) if taken near
mealtimes.

18. Answer D. Cooperative play is typical of the preschool period.

19. Answer C. According to Eriksons theory, older adults need to find
and accept the meaningfulness of their lives, or they may become
depressed, angry, and fear death. Reminiscing contributes to successful
adaptation by maintaining self-esteem, reaffirming identity, and working
through loss.

20. Answer D. Beef and beans are an excellent source of protein as is
skim milk. Strawberries are a good source of Vitamin C.

1. Which age group has the greatest potential to demonstrate regression when they
are sick?
1. Adolescent
2. Young Adult
3. Toddler
4. Infant
2. Which is a major concern when providing drug therapy for older adults?
1. Alcohol is used by older adults to cope with the multiple problems of aging
2. Hepatic clearance is reduced in older adults
3. Older adults have difficulty in swallowing large tablets
4. Older adults may chew on tablets instead of swallowing them.
3. One of the participants attending a parenting class asks the teacher what is the
leading cause of death during the first month of life?
1. Congenital Abnormalities
2. Low birth weight
3. SIDS
4. Infection
4. Which stage of development is most unstable and challenging regarding
development of personal identity?
1. Adolescence
2. Toddler hood
3. Childhood
4. Infancy
5. Which age group would have a tendency towards eating disorders?
A. Adolescence
B. Toddler hood
C. Childhood
D. Infancy
6. When assessing an older adult. The nurse may expect an increase in:
1. Nail growth
2. Skin turgor
3. Urine residual
4. Nerve conduction
7. A maternity nurse is providing instruction to a new mother regarding the
psychosocial development of the newborn infant. Using Eriksons psychosocial
development theory, the nurse would instruct the mother to
1. Allow the newborn infant to signal a need
2. Anticipate all of the needs of the newborn infant
3. Avoid the newborn infant during the first 10 minutes of crying
4. Attend to the newborn infant immediately when crying
8. A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly
and having temper tantrums. The nurse most appropriately tells the mother to:
1. Punish the child every time the child says no, to change the behavior
2. Allow the behavior because this is normal at this age period
3. Set limits on the childs behavior
4. Ignore the child when this behavior occurs
9. The parents of a 2-year-old arrive at a hospital to visit their child. The child is in the
playroom when the parents arrive. When the parents enter the playroom, the child
does not readily approach the parents. The nurse interprets this behavior as
indicating that:
1. The child is withdrawn
2. The child is self-centered
3. The child has adjusted to the hospitalized setting
4. This is a normal pattern
10. The mother of a 3-year-old is concerned because her child still is insisting on a
bottle at nap time and at bedtime. Which of the following is the most appropriate
suggestion to the mother?
1. Do not allow the child to have the bottle
2. Allow the bottle during naps but not at bedtime
3. Allow the bottle if it contains juice
4. Allow the bottle if it contains water
11. A nurse is evaluating the developmental level of a 2-year-old. Which of the
following does the nurse expect to observe in this child?
1. Uses a fork to eat
2. Uses a cup to drink
3. Uses a knife for cutting food
4. Pours own milk into a cup
12. The nurse is providing an educational session to new employees, and the topic is
abuse to the older client. The nurse tells the employees that which client is most
characteristic of a victim of abuse
1. A 90-year-old woman with advanced Parkinsons disease
2. A 68-year-old man with newly diagnosed cataracts
3. A 70-year-old woman with early diagnosed Lymes disease
4. A 74-year-old man with moderate hypertension
13. The home care nurse is visiting an older female client whose husband died 6
months ago. Which behavior, by the client, indicates ineffective coping?
1. Visiting her husbands grave once a month
2. Participating in a senior citizens program
3. Looking at old snapshots of her family
4. Neglecting her personal grooming
14. A clinic nurse assesses the communication patterns of a 5-month-old infant. The
nurse determines that the infant is demonstrating the highest level of developmental
achievement expected if the infant:
1. Uses simple words such as mama
2. Uses monosyllabic babbling
3. Links syllables together
4. Coos when comforted
15. A nurse is preparing to care for a 5-year-old who has been placed in traction
following a fracture of the femur. The nurse plans care, knowing that which of the
following is the most appropriate activity for this child?
1. Large picture books
2. A radio
3. Crayons and coloring book
4. A sports video
16. A 16-year-old is admitted to the hospital for acute appendicitis, and an
appendectomy is performed. Which of the following nursing interventions is most
appropriate to facilitate normal growth and development?
1. Allow the family to bring in the childs favorite computer games
2. Encourage the parents to room-in with the child
3. Encourage the child to rest and read
4. Allow the child to participate in activities with other individuals in the same age group
when the condition permits
17. The mother of a toddler asks a nurse when it is safe to place the car safety seat in
a face-forward position. The best nursing response is which of the following?
1. When the toddler weighs 20 lbs
2. The seat should not be placed in a face-forward position unless there are safety locks in
the car
3. The seat should never be place in a face-forward position because the risk of the child
unbuckling the harness
4. When the weight of the toddler is greater than 40 lbs
18. The nurse is caring for an agitated older client with Alzheimers disease. Which
nursing intervention most likely would calm the client?
1. Playing a radio
2. Turning the lights out
3. Putting an arm around the clients waist
4. Encouraging group participation
19. The nurse who volunteers at a senior citizens center is planning activities for the
members who attend the center. Which activity would best promote health and
maintenance for these senior citizens?
1. Gardening every day for an hour
2. Cycling 3 times a week for 20 minutes
3. Sculpting once a week for 40 minutes
4. Walking 3 to 5 times a week for 30 minutes
20. A 16 year old child is hospitalized, according to Erik Erikson, what is an
appropriate intervention?
1. tell the friends to visit the child
2. encourage patient to help child learn lessons missed
3. call the priest to intervene
4. tell the childs girlfriend to visit the child.
Answers and Rationale
1. Answer: 3
2. Answer: 2
3. Answer: 3
4. Answer: 1
5. Answer: 1
6. Answer: 3
7. Answer: 1. According to Erikson, the caregiver should not try to anticipate the newborn
infants needs at all times but must allow the newborn infant to signal needs. If a newborn is
not allowed to signal a need, the newborn will not learn how to control the environment.
Erikson believed that a delayed or prolonged response to a newborns signal would inhibit
the development of trust and lead to mistrust of others.
8. Answer: 3. According to Erikson, the child focuses on independence between ages 1 and
3 years. Gaining independence often means that the child has to rebel against the parents
wishes. Saying things like no or mine and having temper tantrums are common during
this period of development. Being consistent and setting limits on the childs behavior are
the necessary elements.
9. Answer: 4. The phases through which young children progress when separated from their
parents include protest, despair, and denial or detachment. In the stage of protest, when the
parents return, the child readily goes to them. In the stage of despair, the child may not
approach them readily or may cling to a parent. In denial or detachment, when the parents
return, the child becomes cheerful, interested in the environment and new persons
(seemingly unaware of the lost parents), friendly with the staff, and interested in developing
superficial relationships.
10. Answer: 4. A toddler should never be allowed to fall asleep with a bottle containing milk,
juice, soda, or sweetened water because of the risk or nursing caries. If a bottle is allowed
at naptime or bedtime, it should contain only water.
11. Answer: 2. By age 2 years, the child can use a cup and can use a spoon correctly but
with some spilling. By ages 3 to 4, the child begins to use a fork. By the end of the
preschool period, the child should be able to pour milk into a cup and begin to use a knife
for cutting.
12. Answer: 1. The typical abuse victim is a woman of advanced age with few social
contacts and at least one physical or mental impairment that limits the ability to perform
activities of daily living. In addition, the client usually lives alone or with the abuser and
depends on the abuser for care.
13. Answer: 4. Coping mechanisms are behaviors used to decrease stress and anxiety. In
response to a death, ineffective coping is manifested by an extreme behavior that in some
instances may be harmful to the individual physically or psychologically. Option D is
indicative of a behavior that identifies an ineffective coping behavior in the grieving process.
14. Answer: 2. Using monosyllabic babbling occurs between 3 and 6 months of age. Using
simple words such as mama occurs between 9 and 12 months. Linking syllables together
when communicating occurs between 6 and 9 months. Cooing begins at birth and continues
until 2 months.
15. Answer: 3. In the preschooler, play is simple and imaginative and includes activities
such as crayons and coloring books, puppets, felt and magnetic boards, and Play-Doh.
Large picture books are most appropriate for the infant. A radio and a sports video are most
appropriate for the adolescent.
16. Answer: 4. Adolescents often are not sure whether they want their parents with them
when they are hospitalized. Because of the importance of the peer group, separation from
friends is a source of anxiety. Ideally, the members of the peer group will support their ill
friend. Options a, b, and c isolate the child from the peer group.
17. Answer: 1. The transition point for switching to the forward facing position is defined by
the manufacturer of the convertible car safety seat but is generally at a bodyweight of 9 kg
or 20 lb and 1 year of age. Convertible car safety seats are used until the child weighs at
least 40 lb. Options b, c, and d are incorrect
18. Answer: 3. Nursing interventions for the client with Alzheimers disease who is angry,
frustrated, or hostile include decreasing environmental stimuli, approaching the client calmly
and with assurance, not demanding anything from the client, and distracting the client. For
the nurse to reach out, touch, hold a hand, put an arm around the waist, or in some way
maintain physical contact is important. Playing a radio may increase stimuli, and turning the
lights out may produce more agitation. The client with Alzheimers disease would not be a
candidate for group work if the client is agitated.
19. Answer: 4. Exercise and activity are essential for health promotion and maintenance in
the older adult and to achieve an optimal level of functioning. About half of the physical
deterioration of the older client is caused by disuse rather that by the aging process or
disease. One of the best exercises for an older adult is walking, progressing to 30 minutes
session 3 to 5 times each week. Swimming and dancing are also beneficial.
20. Answer: a. tell the friends to visit the child
The child is 16 years old, In the stage of IDENTITY VS. ROLE CONFUSION. The most
significant persons in this group are the PEERS. B refers to children in the school age while
C refers to the young adulthood stage of INTIMACY VS. ISOLATION. The child is not dying
and the situation did not even talk about the childs belief therefore, calling the priest is
unnecessary.